Consent Form

Patient Information





Please type your initials after each statement:







I understand Ketamine is a widely and successfully used medication and there have been no promises or guarantees as to the effectiveness or safety of Ketamine treatment(s). I understand that there are risks, complications, side effects, and dangers of any medical treatment including Ketamine treatment which I have been clearly informed about, and I accept such risks, complications, side effects and dangers and clearly and intelligently consent to the Ketamine treatment(s).

I understand that Dr. Soler-Baillo and the staff of Ketamine Life Centers are not responsible for the risks, complications, side effects and dangers associated Ketamine treatment(s) and fully release Dr. Soler-Baillo and his staff from any damages and injuries which might be suffered from the use of this medication.

I have researched the uses of Ketamine or have had a fair opportunity to research the uses of Ketamine, have obtained a second opinion or had a fair chance to get a second opinion about Ketamine, and have asked questions or had a fair chance to ask questions about about this medication and have no questions about this treatment.

I hereby release Dr. Soler-Baillo and Ketamine Life Centers from any liability for the administration of the product known as Ketamine even if there are complications, side effects, damages or injuries, known or not known to exist, which occur, whether said factors are inherent to the use of the medication or as a result of the negligence or liability of the manufacturer or even as a result of the negligence of Dr. Soler-Baillo and the staff of Ketamine Life Centers, without exception.

This does not release the manufacturer of Ketamine.


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